A Médecins Sans Frontières team was scrambling at the height of the Ebola crisis in West Africa in 2015. They needed to step up their contact tracing of potentially infected victims to stop the chain of Ebola transmission — but they didn’t have reliable geographic information of villages in the Tonkolili district of Sierra Leone.
So they came up with a plan: recruit motorbike taxi drivers with GPS-enabled Android smartphones, install an open-source survey software on their phones, then train them to collect the GPS coordinates of each village in the district.
The result, two weeks later, was a map of 950 villages in Tonkolili. And it came with a bonus: the name and phone number of each village leader and local health care worker, population in the village, number of households, and the location of the closest health facility.
The initiative was, by many accounts, a huge success, and opened up possibilities of being adopted outside Tonkolili and beyond the context of Ebola.
But Dr. Kiran Jobanputra, deputy head of MSF’s Manson Unit in London, who similarly lauded it as a “great and simple idea,” argued it raised specific ethical concerns — on confidentiality, consent, data security and the ethical duty of “do no harm.” Did MSF carefully consider the risks the mappers were being exposed to and put proper mitigation measures in place? The mappers may have not taken individual village people’s data, but what if only one or two households live in a given area? Had the organization thought of the potential consequences if such data were exposed?
These were questions the international medical humanitarian organization has found itself dealing with increasingly for the past few years, both internally and from other humanitarian actors.
Questions on ethics are growing as fast as growth in innovation.
“Over the last few years … we see more and more of a gray area between research and innovation, and particularly, more and more things we call operational innovation raise ethical concerns,” Jobanputra told Devex ahead of the organization’s annual Scientific Days on May 20-21.
And this isn’t exclusive to MSF. Last year, Chris Earney, co-lead on innovation at the U.N. refugee agency, identified five points humanitarian organizations should keep in mind when creating a system of ethics for their innovations.
“We need to talk about this right now, and we need to begin by framing this conversation in the context of the needs of field operations,” he said in a blog post for UNHCR Innovation, titled “Humanitarian innovation ethics. Get some.”
The Refugee Studies Center at the University of Oxford also came out with seven principles for ethical humanitarian innovation in June 2015.
The framework
In medical research, any MSF action that involves patients and their data is required to run through the organization’s Ethics Review Board as well as the ethics review boards of countries where the research is being undertaken. Operational innovations being taken in the field, meanwhile — such as the placement of a wash basin inside a hospital tent for patient safety and infection control, don’t have to.
However, when these innovations have the potential to impact communities or groups of people — as was the case with the motorbike mapping approach — then ethical issues need to be considered.
That’s why the medical organization has put together its own ethical framework that, Jobanputra hopes, will guide more innovations adopted in the field. He emphasized the one-page framework — a draft of which Devex obtained in advance of its official publication — is not meant to discourage MSF teams from innovating, only that they do so in an ethically responsible, respectful manner, and with minimized risks of harm.
“Our vision is for it to be the simplest possible tool that a nonethicist, nonresearcher can use to provide some ethical oversight for their innovation,” he said.
The framework — agreed between MSF medical doctors and directors, people involved in operations such as a senior logistician and a project manager, and three medical ethicists — contains six ethical points innovators are expected to consider, including respect for people’s privacy and their personal data, the balance between potential harms and benefits resulting from an innovation, and the necessary evaluation and roll-out plan if a pilot goes well.
The motorbike mapping project is an example of a field-led innovation where the potential benefits likely outweighed the potential harms, according to Jobanputra. While the locally recruited mappers had an increased exposure to the Ebola virus, the medical doctor found this was mitigated by the deployed MSF team when they provided daily health education briefings, such as reminders on the no-touch policy, including with objects or surfaces that may have been in contact with infected people; self-assessments on personal health; and hand-washing.
The mappers’ risk of being subjected to violence was also mitigated by the team’s instructions to politely ask permissions from village authorities to conduct the surveys and to never argue if asked to leave.
“If this technology were used in conflict zones, it might create anxiety about the data falling into the wrong hands, which could be managed by the use of secure MSF servers. But in the case of the Ebola epidemic response, the potential benefits of accurate mapping were very significant, and were felt to compare favorably with the smaller risk of harm,” Jobanputra said.
The ethics team has already tried applying the framework on a number of innovations, including in using drones to transport tuberculosis sputum samples and in fixing malfunctioned boreholes in Niger, and feel confident of its capability to identify the different ethical issues field staff face on the ground.
Yet, despite the progress, Jobanputra is managing his expectations.
“Ideally, the framework would be so ubiquitous that a field team would access [it] when they are innovating. [But] we cannot be prescriptive, because the way that MSF works, it’s a very collaborative movement. We can’t impose this sort of framework on everybody,” he said.
Nevertheless, his team will make the framework available for everyone and encourage all MSF field staff to use it. Around the same time next year, they plan to conduct a review and see how many of the innovations adopted in the field have made good use of it — or at least the more than 100 innovations that reach headquarters each year, adding that as most innovations respond to an “immediate field problem,” they usually fly under the headquarters’ radar.
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